Diabetes is the seventh leading cause of death in the U.S. and increases the risk of death twofold over age-matched individuals. Even these are conservative numbers, as diabetes has been found to be underreported on death certificates (1). These findings are even more remarkable for the recent decline seen in diabetes mortality rates due to improved management of cardiovascular risk factors (2). Despite remarkable advances in our understanding of the disease and pharmacological interventions for its treatment, diabetes remains the leading cause of renal failure, nontraumatic lower-limb amputation, and blindness in working-age adults. Improved therapeutics and health care delivery have brought remarkable declines in the incidence of both diabetic microvascular and macrovascular complications, with a 50% reduction in amputations from their peak in 1997 and ∼35% reduction in the incidence of end-stage renal disease (3). Similarly, 10-year coronary heart disease risk dropped from 21% in 2000 to 16% in 2008 (4).

The observed decline in the event rates of complications and death due to diabetes is swamped by the increase in the number of individuals affected by the disease. The multiplier effect of a growing population with diabetes converts a declining incidence of complications into an increase in the total number of events observed. Among adults aged 18–79 years, the number of individuals with diagnosed diabetes in the U.S. increased from approximately 12 million in 2000 to over 20 million in 2010 (3). The Centers for Disease Control and Prevention has projected that by 2050 as many as 33% of U.S. adults could have diabetes (5). These growth figures project intolerable numbers of cardiac events, amputations, and occurrences of renal failure despite our improved care and diminishing risk.

The last survey of health care costs attributable to diabetes was undertaken in 2007 by the American Diabetes Association (6). An individual with diabetes had average medical expenditures 2.3 times those for a matched population without diabetes. Total direct and indirect costs rose 33% from 2002 to a total of $174 billion. The American Diabetes Association is currently undertaking a repeat of this economic cost analysis with publication expected in early 2013. Given the increased prevalence of diabetes, there is no reason to believe that the direct medical costs will not continue to increase at this unacceptable rate.

The article in this issue of Diabetes Care by Imperatore et al. (7) significantly increases the concern over diabetes demographics, complications, and costs. Previous estimates of diabetes growth focused on adults. Now we see the impact of demographic changes in the U.S. and the rising rates of obesity-related type 2 diabetes in children and adolescents, as well as increasing rates of type 1 diabetes. Their estimates of a 23% increase in type 1 diabetes and a 49% increase in type 2 diabetes over the next 40 years assume no further increase in the incidence of the disease, whereas demographic shifts in the population of minorities in the U.S. could increase the prevalence by three- to fourfold.

In his speech last week, Genachowski also mentioned the advent of 4G wireless Internet access as an occasion for national celebration. He is right that 4G may provide a substitute for slow cable connectivity. But data caps imposed by the dominant wireless carriers, AT&T Inc. and Verizon Wireless, make getting access to boatloads of data by way of a wireless device unimaginable for most Americans.

In any case, no one is claiming that 4G will bring gigabits to the U.S. In order to get even advertised 4G speeds, you have to be close to a tower, and there can’t be too many other people sharing the connection. True, there is discussion about developing very-high-capacity wireless connections that rely on stable, accurate point-to-point transmissions blasted across wide bands of radio frequencies not subject to interference from, say, leaves or rain. For anyone relying on a mobile device while moving through life, none of these conditions will be in place.

No Incentive

So wireless can never be a full substitute for a wired connection. More broadly, fiber policy is wireless policy: With competitive fiber installed in more American neighborhoods, we would all have better mobile data connections. As things stand, the incumbent cable companies have no particular competitive or regulatory incentive to install that fiber.

Given these realities as well as other obstacles -- for example, existing providers often control poles to which competitors need access -- Genachowski’s call for more “test beds” may not actually bring Americans cheaper, faster or better network access. At least, though, the FCC is now talking about gigabits.

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Her new book, Captive Audience: The Telecom Industry and Monopoly Power in the New Gilded Age, is excellent. (caveat - Susan is s friend).

There are any number of engineering issues associated with making this bicycle prototype work and ride well, but the idea of an asymmetrical frame on 36 inch wheels is an interesting thought. A concept by designer Paolo de Ciusti